A Pharmacy Benefit Forecast for 2015 By SARAH MARTIN
As 2015 approaches, what are the most important new trends you should understand related to pharmacy benefits? The Lockton Benefit Group Pharmacy Analytics Practice breaks down the issues and provides some practical advice for smart decision-making. If you have questions or concerns related to these or other pharmacy benefit issues, please contact your Lockton Account Team.
ISSUE 1
Unexpected fees may be associated with a combined pharmacy/medical out-of-pocket maximum.
If you haven’t already made a decision about whether to use two separate out-of-pocket maximums (one for medical and one for pharmacy) or a single, combined out-of-pocket maximum, it’s time to do so. If your pharmacy benefit is carved out to a pharmacy benefit manager (PBM), keep in mind you might be paying data integration fees to your carrier, PBM, or both if you decide to maintain a single out-of-pocket (OOP) maximum for both medical and pharmacy cost sharing. Some PBMs and carriers are offering a choice between near real-time data exchange or overnight batch-data transfers. Data transfer fees can vary from $0 to thousands of dollars per month.
ISSUE 2
Expect an increasing hepatitis C spend. We saw hepatitis C and the wonder drug, Sovaldi, in the news throughout 2014. New oral hepatitis C medications are projected to cost even more than Sovaldi, which runs approximately $84,000 per treatment. The good news about all of these treatments is the cure rates are very high—90 percent or more. Two oral hepatitis C treatments to watch for are currently under FDA review and expected to be approved in the fourth quarter of 2014. Additional treatments should be available in 2015. Some of the new treatments expand the population of patients who can be treated, while others may actually bring price competition to the class. Lockton’s Pharmacy Analytics Practice can assist you with strategies to manage your hepatitis C spend appropriately and take advantage of price competition when it becomes available. We can also conduct predictive modeling to estimate future hepatitis C costs for your plan.
ISSUE 3
A robust specialty drug pipeline exists for new breakthrough therapies. In addition to new hepatitis C treatments, we expect new oncology medications to be released throughout 2015, with some costing an average of $10,000 per patient per month. Two new oral therapies for idiopathic pulmonary fibrosis (IDF), a lung disorder with no cure, could run $100,000 per patient per year. These breakthrough therapies may prevent the progression of the disease, which is exciting because currently the primary treatment available for IDF is a lung transplant. A new oral therapy for cystic fibrosis (CF) could benefit 50 percent of all CF patients. The cost of the new treatment is expected to be at least $300,000 per patient per year. This is important because Kalydeco, a treatment that was approved in 2012 to treat the underlying cause of CF, is effective in only five percent of patients.
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